opioid epidemic

North America

United States

From 1999 to 2021 it is estimated 645,000 Americans have died from opioid use. The number of overdose deaths involving opioids in 2021 was ten times what it was in 1999. What the U.S. Surgeon General dubbed "The Opioid Crisis" was theorized to have been caused by the over-prescription of opioids in the 1990s, which led to the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016 and the resulting impact on medical access to prescription opioids "outside of active cancer treatment, palliative and end of life." Opioids initiated for post-surgical pain management have long been debated as one of the causative factors in the opioid crisis, with misuse/abuse estimated at 4.3% of people continuing opioid use after trauma or surgery.

When people continue to use opioids beyond what a doctor prescribes, or when opioids are over-prescribed, whether to minimize pain or induce euphoric feelings, it can mark the beginning stages of an opiate addiction, with a tolerance developing and eventually leading to dependence, when a person relies on the drug to prevent withdrawal symptoms. Writers have pointed to a widespread desire among the public to find a pill for any problem, even if a better solution might be a lifestyle change, such as exercise, improved diet and stress reduction. Opioids are relatively inexpensive, and alternative interventions, such as physical therapy, may not be affordable.

In 2017, around 100 million people or a third of the U.S. population was estimated to be affected by chronic pain at any given time. This led to a push by drug companies and the federal government to expand the use of painkilling opioids. In the 1990's, initiatives like the Joint Commission began to push for more attentive physician response to patient pain, referring to pain as the fifth vital sign. This exacerbated the already increasing number of opioids being prescribed by doctors to patients.

Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year. In 2016, more than 289 million prescriptions were written for opioid drugs. This was exacerbated by the aggressive and misleading marketing of drug makers, e.g. Purdue Pharma. Purdue trained its sales representatives to convey to doctors that the risk of addiction from OxyContin was "less than one percent."

Mirroring the growth of opioid pain relievers prescribed was an increase in the admissions for substance abuse treatments and opioid-related deaths. This illustrates how legitimate clinical prescriptions of pain relievers were diverted through an illegitimate market, leading to misuse, addiction, and death. With the increase in volume, the potency of opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine. By 2012, the ratio had doubled to one in three. The most commonly prescribed opioids have been oxycodone and hydrocodone.

Canada

In 1993, an investigation by the chief coroner in British Columbia identified an "inordinately high number" of drug-related deaths, of which there were 330. In 2016, there were 2,861 opioid related deaths in Canada. In 2017, there were 1,473 deaths in British Columbia and 3,996 deaths in Canada as a whole. Between 2016 and 2022 Canada saw a two and a half fold increase in the per capita rate of opioid related deaths, reaching 20.3 per 100,000 population per year, with 1,904 deaths reported in the first 3 months of 2023 alone.

In 2015, Canada was identified as the second-highest per-capita user of prescription opioids, behind the United States. In Alberta, emergency department visits as a result of opiate overdose, attributable to both prescription and illicit opioids, specifically fentanyl and fentanyl analogues, rose 1,000% in the previous five years. The Canadian Institute for Health Information found that while a third of overdoses were intentional overall, among those ages 15–24 nearly half were intentional. In 2017, there were 3,987 opioid-related deaths in Canada, 92% of these deaths being unintentional. The number of deaths involving fentanyl or fentanyl analogues increased by 17% compared to 2016.

Between April and December 2020, there was an 89% increase in opioid related deaths in comparison to 2019. Saskatoon, Saskatchewan experienced a record month in opioid overdoses in May 2020 caused, authorities explained, by a combination of ever-amplifying toxic drugs and the COVID-19 pandemic's quarantine keeping individuals from family and needed mental health services. Over 28,800 Emergency Medical Services (EMS) responded to possible opioid related health crises between January and December 2020 after the COVID-19 pandemic began. In May 2020, Medavie Health Services provided over 250 ambulance services for overdoses, administering the opioid antagonist nasal spray Narcan (naloxone) in record numbers.

North America's first safe injection site, Insite, opened in the Downtown Eastside (DTES) neighborhood of Vancouver in 2003. Safe injection sites are legally sanctioned, medically supervised facilities in which individuals are able to consume illicit recreational drugs, as part of a harm reduction approach towards drug problems, which includes information about drugs and basic health care, counseling, sterile injection equipment, treatment referrals, and access to medical staff, for instance in the event of an overdose. In 2017, Health Canada licensed 16 safe injection sites nationally. In Canada, about half of overdoses resulting in hospitalization were accidental, while a third were deliberate overdoses.

Outside North America

In 2023, opioid seizures by authorities in Africa accounted for half of the global seizures of opioids, particularly tramadol. In the 2010s, opioids became a serious problem outside the U.S., mostly among young adults. According to an epidemiologist at Columbia University: "Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn't it work elsewhere?"

Many deaths worldwide from opioids and prescription drugs are from sexually transmitted infections passed through shared needles. This has led to a global initiative of needle exchange programs and research into the varying needle types carrying STIs. Some worry that the epidemic could become a worldwide pandemic if not curtailed. In 2017, prescription drug abuse among teenagers in Canada, Australia, and Europe was comparable to U.S. teenagers.

In 2017, in Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom. In 2017, 1,049 people had a death related to opioids in Spain.

While strong opiates are heavily regulated within the European Union, there is a "hidden addiction" with codeine. Codeine, though a mild painkiller, is converted into morphine in the liver. "It's a hidden addiction,' said Dr Michael Bergin of Waterford Institute of Technology, Ireland. 'Codeine abuse affects people with diverse profiles, from children to older people across all social classes."

Asia

In May 2020, Myanmar and the U.N. Office of Drugs and Crime (UNODC) announced that, over the previous three months, police had confiscated illicit drugs with a street value estimated at hundreds of millions of dollars. Most was methamphetamine. They also seized 3,750 liters (990 US gallons) of the potent opiate liquid methylfentanyl.

In 2022, Iran had the highest rate of nonmedical opium use in the world. Proximity to opiates produced in Afghanistan and Pakistan make Iranian society vulnerable to opiate addiction in the past, however since the Taliban since coming into power in Afghanistan has cracked down on opium poppy cultivation and opioid use, potentially lowering the risk of the neighbouring countries sourcing a supply.

Oceania

In Australia, approximately 60% of drug related deaths are attributed to opioids; a vast majority of which are legal pharmaceuticals such as oxycodone (commonly as Targin ER or Endone) and codeine (Panadeine, Nurofen Plus) rather than illicit heroin or fentanyl. Monash University has claimed that opioids are over-prescribed in Australia, and cited a clinical trial which found that patients with chronic low-back pain or that of the neck experienced a minimal or no difference between oxycodone and placebo in terms of pain management.

Daily in Australia, hospitals receive approximately 150 patients who are experiencing opioid-related health issues, with 3 dying. In 2016-17, 15.4 million prescriptions of opioids were given to 3.1 million Australians; an increase in prescriptions, but generally for lower oral morphine equivalent than in prior years.

Possession of illicit opioids such as heroin and fentanyl, as well as diverted pharmaceutical opioids, is decriminalized in the Australian Capital Territory. Supervised injection sites, pill testing, and opioid-assisted therapy for opioid use disorder are available in varying parts of the country.

Europe

In 2017, in Europe, prescription opioids accounted for three‐quarter of overdose deaths, which represented 3.5% of total deaths among 15-39-year-olds. While deaths from overdoses related to illicit fentanyl and oxycodone are relatively rare in the UK and Europe, fatal outcomes from opioid intoxications have seen a moderate increase since 2015. In continental Europe, the rise of deaths as a result of opioid/opiate use had been partly due to chronic illnesses of addicts 40 years and older, but some of the recent deaths were experienced by younger users experimenting with 'designer drugs'. Generally speaking, the use of fentanyl by addicts in Europe has been rare as of 2022, but at the same time general deaths from opioid use have increased by 177% since 2019. As in other parts of the Western world, the COVID-19 pandemic has brought a reduced availability of therapies for addicts, but at the same time increased the availability of synthetic opioids on the black market.

From January to August 2017, there were 60 fatal overdoses of fentanyl in the UK. In England, opioid prescribing in general practice mirrors general geographical health inequalities. In July 2019, two Surrey GPs working for a Farnham-based online pharmacy were suspended by the General Medical Council for prescribing opioids online without appropriate safeguards. Public Health England reported in September 2019 that half the patients using strong painkillers, antidepressants and sleeping tablets had been on them for more than a year, which was generally longer than was "clinically" appropriate and where the risks could outweigh the benefits. They found that problems in the UK were less than in most comparable countries, but there were 4,359 deaths related to drug poisoning, largely opioids, in England and Wales in 2018 – the highest number recorded since 1993.

Public Health England reported in September 2019 that 11.5 million adults in England had been prescribed benzodiazepines, Z-drugs, gabapentinoids, opioids, or antidepressants in the year ending March 2018. Half of these had been prescribed for at least a year. About 540,000 had been prescribed opioids continuously for three years or more. Prescribing of opioids and Z-drugs had decreased, but antidepressants and gabapentinoids had increased, gabapentinoids by 19% between 2015 and 2018 to around 1.5 million.

It was reported that in 2021/2022, 1.80 million patients were prescribed dependency-forming medicines in the most deprived areas in England, 1.66 times more than the number prescribed these medicines in the least deprived areas. This pattern had been consistent since 2015/2016.

Africa

There were 4 million people misusing opioids in Nigeria in 2025, driven by unlicensed, highly addictive opioids illegally exported from India. A 2024 BBC investigation exposed Aveo Pharmaceuticals, a Mumbai-based company, as a key supplier of Tafrodol and similar pills, which contain tapentadol, a potent opioid, and carisoprodol, a highly addictive muscle relaxant banned in Europe. This combination has led to severe addiction, overdoses, and painful withdrawal symptoms.

The rise of these opioids followed tramadol restrictions in Nigeria and India, creating a demand for new alternatives. These combination pills are now cheap and widely available on the streets of Ghana, Nigeria, and Ivory Coast, devastating the lives of millions of young people and prompting local leaders to form vigilante groups to seize and destroy the drugs.

Accessibility of prescribed opioids

The worry surrounding the potential of a worldwide pandemic has affected opioid accessibility in countries around the world. Approximately 25.5 million people per year, including 2.5 million children, die without pain relief worldwide, with many of these cases occurring in low and middle-income countries. The current disparity in accessibility to pain relief in various countries is significant. The U.S. produces or imports 30 times as much pain relief medication as it needs, while low-income countries such as Nigeria receive less than 0.2% of what they need. 90% of all the morphine in the world is used by the world's richest 10%.

America's opioid epidemic has resulted in an "opiophobia" that is stirring conversations among some Western legislators and philanthropists about adopting a "war on drugs rhetoric" to oppose the idea of increasing opioid accessibility in other countries, in fear of starting similar opioid epidemics abroad. The International Narcotics Control Board (INCB), a monitoring agency established by the U.N. to prevent addiction and ensure appropriate opioid availability for medical use, has written model laws limiting opioid accessibility that it encourages countries to enact. Many of these laws more significantly impact low-income countries; for instance, one model law ruled that only doctors could supply opioids, which limited opioid accessibility in poorer countries that had a scarce number of doctors.

In 2018, deputy head of China's National Narcotics Commission Liu Yuejin criticized the U.S. market's role in driving opioid demand.

In 2016, it was reported that while Mexican cartels are the main source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl and the machinery necessary for its production. In 2016 in British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015. In 2016 in Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents. Each machine was capable of producing thousands of pills an hour.

In 2018, a woman died in London after getting a prescription for tramadol from an online doctor based in Prague who had not considered her medical history. Regulators in the UK admitted that there was nothing they could do to stop this from happening again. A reporter from The Times was able to buy opioids from five online pharmacies in September 2019 without any contact with their GP by filling in an online questionnaire and sending a photocopy of their passport.

Alternative for opioids

Alternative drug options for opioids include over the counter pain medication such as Ibuprofen, Tylenol (acetaminophen/paracetamol), and Aspirin or steroid options. A German study comparing legal opioid use between different countries concluded that a high consumption of oxycodone could be attributed to the non-availability of the drug metamizole, a non-opioid pain reliever which is heavily used in some countries such as Germany and Austria, but which is banned in others such as the US and Canada.

Along with drug alternatives, many other alternatives can provide relief through physical activities. Physical therapy, acupuncture, injections/nerve blocks, massages, and relaxation techniques are physical activities that have been found to help with chronic pain. New pain management drugs like cannabis and cannabinoids have also been found to help treat symptoms of pain. Many treatments like cancer treatments are using these drugs to help manage pain.

An alternative for opioid addiction are opioid receptor agonists or full opioid receptor agonist drugs like methadone, which is also a analgesic and can be used in the treatment of pain in opioid tolerant patients as an extremely safe treatment of choice in hospital settings. Methadone is an opioid, and treatment of pain (over NSAIDs for example) in this form does include opioids; it is, however, an alternative to opioid addiction as a somewhat effective method of eventually reducing opioid use. On the other hand (of methadone, and in opioid addiction treatment), buprenorphine (commonly known as subutex, suboxone) is an easier opioid to taper from, is an alternate opioid with a lower potential for abuse, comes with many contraindications and restrictions.

Signs of addiction

People that are addicted to opioids can have many changes in behavior. Some of the common signs or symptoms of addiction include spending more time alone, losing interest in activities, quickly changing moods, sleeping at odd hours, getting in trouble with the law, and financial hardships. People that notice any of these behaviors in a peer or in oneself, are usually advised to consult a physician.

Treatment and prevention of addiction

Opioid use disorder can be treated in a number of different ways: Medication assisted treatment pathways offer methadone, Suboxone (Buprenorphine/naloxone) and Vivitrol (naltrexone), though naltrexone has poor treatment outcomes due to low patient retention.

According to the 2017 Surgeon General's report, medication (buprenorphine/methadone) assisted therapies (MAT's) remain the gold standard in evidence-based care for opiate addiction, with the highest reduction in morbidity, mortality, and general negative outcomes achieved through long term opioid replacement therapy. The report makes recommendations concerning expanding access to MAT in order to combat the opioid epidemic. Social stigma regarding medication-assisted treatment in nations like the USA have been a major barrier in implementing evidence based treatments for opiate addiction.

Cognitive behavioral therapies and counseling are proven effective (though less efficacious on their own than medication assisted therapies) as well as digital care programs to increase abstinence rates.

An emerging area in opioid risk prevention is the use of genetic tests intended to inform prescribing decisions. In 2024, the U.S. Food and Drug Administration (FDA) authorized AvertD, a genetic test designed to identify elevated risk of Opioid use disorder in opioid-naïve adults being considered for short-term opioid prescriptions. The test analyzes a panel of genetic variants associated with addiction risk to generate a probabilistic risk classification intended to support clinical decision-making rather than provide a diagnosis.

Researchers and clinicians have debated the potential role of genetic risk prediction in addiction medicine. Some argue that such tools could help physicians better assess risks when prescribing opioids, particularly in contexts such as post-surgical pain management. Others have raised concerns about the current predictive accuracy of genetic risk scores, the possibility of unequal performance across ancestry groups, and the risk that genetic risk classification could contribute to undertreatment of pain or reinforce stigma surrounding substance use disorders.

Anti-opioid advertisements

A number of methods for the prevention of opioid addiction have been used and suggested. One method is the creation of anti-opioid advertisements. In the 1990s, advertisements depicting drug-seeking people purposefully slamming their arms into doors and crashing their cars, were unsuccessfully targeted at teens. These ads were unsuccessful because they emphasized the risk of danger, pain, and death caused by opioids. While this tactic would make adults acknowledge the risks and stop using opioids, for many teenagers, the perceived danger adds to the appeal, as smoking becomes a form of rebellion against authoritative adults.

When ads were created that instead channeled teenage rebellion toward resisting the tobacco industry's manipulative tactics, the numbers of teens smoking went down. The makers of these ads feel that since the internet allows teenagers to view gruesome things anyway, it is perfectly acceptable to subject them to images of self-mutilation in order to protect their lives. It is felt that thirty seconds of gruesomeness is a small price to pay for sparing a lifetime (however short) of opioid abuse and its accompanying poverty and crime.

These advertisements, which started in the 1980s, are continuing to play on television today, utilizing donated advertisement time. The goals of the most recent advertisements are to show teenagers that addiction can begin after only five days, and that feeding this addiction can consume a person's entire life.